Plan Sponsor Notices and Other Documents
What's New
11/18/2024: The Office of Management and Budget (OMB) has renewed the Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146). Plan Sponsors must use the current notice until December 31, 2024, and are required to use the new notice beginning January 1, 2025.
The updated Part D denial notices, including Spanish, Chinese, Korean, and Vietnamese translations, are available in the "Downloads" section below.
Additionally, the model notices have been updated and are available for immediate use (see Model Notices below for instructions on the dismissal model notices). Both Microsoft Word and PDF formats are available in the Downloads section at the bottom of this page.
12/20/2024 Update: This notice was released in November 2024, with revisions consistent with regulatory changes in CMS-4205-F, effective January 1, 2025. Part D plan sponsors have expressed concern with implementing the revised notice close to the start of the 2025 plan year, given the need for programming and testing activities. As a result of these concerns, CMS will allow Part D plan sponsors additional time to implement the revised Notice of Denial of Medicare Part D Prescription Drug Coverage. Part D plan sponsors must implement the denial notice as soon as practicable, but no later than April 1, 2025. This extended deadline to implement the revised notice does not alter or amend the applicability date of the regulatory changes in CMS-4205-F.
This page includes a number of notices and other documents for plan sponsors. Questions regarding any of the Part D notices can be submitted through this link: https://appeals.lmi.org/
Standardized Notices
CMS has developed the following standardized notices to be used by plan sponsors:
- Medicare Prescription Drug Coverage and Your Rights ("Pharmacy Notice")
- Notice of Denial of Medicare Part D Prescription Drug Coverage
Medicare Prescription Drug Coverage and Your Rights (CMS-10147)
The standardized notice Medicare Prescription Drug Coverage and Your Rights (CMS-10147) ("pharmacy notice") and form instructions are available in the "Downloads" section below.).
Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146)
The Notice of Denial of Medicare Part D Prescription Drug Coverage, both in English and Spanish, which includes the corresponding instructions is available in the "Downloads" section below.
Effective 11/18/2024: The Office of Management and Budget (OMB) has renewed the Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146). Plan Sponsors must use the current notice until December 31, 2024, and are required to use the new notice beginning January 1, 2025. The zip files containing the new notices are marked with an expiration date of 11/30/2027. CMS has translated this updated notice into Spanish, Korean, Chinese and Vietnamese. All translated version of the notice are available in the download section.
Model Notices
CMS model notices contain all of the elements CMS requires for proper notification to enrollees or prescribers, if applicable. Plan sponsors may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plan sponsors may use these notices at their discretion.
NOTE REGARDING MEDICARE NOTICES WITH QIO INFORMATION:
Providers, suppliers, Medicare Advantage Organizations and Prescription Drug Plans should make certain that their Medicare notices include the correct Quality Improvement Organization (QIO) contact information. Please see www.qioprogram.org for QIO details.
Effective 11/18/2024: The following model notices have been updated and are available for immediate use. Both Microsoft Word and PDF formats are available in the Downloads section at the bottom of this page.
- Notice of Right to an Expedited Grievance
- Notice of Case Status
- Request for Additional Information
- Notice of Inquiry
- DMP Model Redetermination Notice
- Denial of Medicare Drug Coverage
- Medicare Drug Coverage Denial Request for Redetermination
The following notices have been updated to incorporate the regulatory change in the timeframe to submit an appeal from 60 calendar days to 65 days calendar days from the date of the notice. These model notices are available for use beginning 01/01/2025. Medicare health plans should continue to use the current model notices through December 31, 2024.
- Notice of Dismissal of Coverage Request
- Notice of Dismissal of Appeal Request
- Model Redetermination Notice
CMS has published additional guidance through the Health Plan Management System (HPMS) that clarifies a number of issues related to Part D grievances, coverage determinations, and appeals (see "HPMS Guidance History" in the "Related Links" section below).
Downloads
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Notice of Denial of Part D Prescription Drug Coverage CMS-10146 (with Instructions) (ZIP) -
Notice of Denial of Part D Prescription Drug Cvg CMS-10146 LARGE PRINT (with Instructions) (ZIP) -
Model Notice of Case Status_Nov2024v508 (ZIP) -
Notice of Denial Part D Prescription Drug Cvg Translated Forms CMS-10146 Eff 010125 (ZIP) -
Notice of Denial Part D Prescription Drug Cvg English Form & Instructs CMS-10146 Eff 010125 (ZIP) -
Medicare Prescription Drug Coverage and Your Rights (Form CMS-10147 and Instructions) (ZIP) -
Model Notice of Right Expedited Grievance_Part D_Nov2024v508 (ZIP) -
Model Request for Additional Information_Nov2024v508 (ZIP) -
Model Redetermination Notice Nov2024 v508 (ZIP) -
Model Notice of Inquiry_Nov2024v508 (ZIP) -
DMP Model Redetermination Notice Nov2024v508 (ZIP) -
Model Notice of Dismissal of Coverage Request_Dec2021v508 (ZIP) -
Part D - Model Notice of Dismissal of Appeal Request_Dec2021v508 (ZIP) -
Model Notice of Dismissal of Appeal Request Eff 010125 (ZIP) -
Model Notice of Dismissal of Coverage Request Eff 010125 (ZIP)